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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Child maltreatment

Actions to take:

Interview the child separately from the parents

Ask a parent, away from the child

Parameters to monitor:

Signs of fear or apprehension from the child when either parent is present

Negative comments about child from either parent.

Rationale:

Potential Condition: Child Maltreatment

The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.

Actions to Take

Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.

Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.

Parameters to Monitor

Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.

Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.

Potential Diagnoses: Incorrect Choices

Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.

Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.

Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.

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Correct Answer is C

Explanation

A. Rather than helping the child accept a loss of control, atraumatic care focuses on empowering the child and promoting a sense of control through participation in care and decision-making.

B. While pain management is crucial, the goal is not to have the child "accept" pain but to minimize it through interventions like distraction, pharmacologic pain relief, and comfort measures.

C. Preparing the child for unfamiliar treatments or procedures aligns with the principles of atraumatic care, which aim to reduce fear, anxiety, and physical and emotional distress. By offering developmentally appropriate explanations, the nurse helps the child feel more in control and reduces the traumatic impact of the experience.

D. Atraumatic care emphasizes maintaining parental involvement during hospitalization whenever possible. Preparing the child for separation does not align with atraumatic care principles, as separation is a source of stress that should be minimized.

A. Asking the client to look away during the injection to reduce anxiety B. Using a larger needle to ensure accurate insulin delivery C. Administering the insulin injection quickly to minimize discomfort D. Explaining the procedure in simple terms to the client before administering the insulin

Correct Answer is D

Explanation

A. Asking the client to look away may reduce anxiety for some, but it does not minimize discomfort or promote understanding.

B. Using a larger needle would likely increase discomfort and is not consistent with atraumatic care, which aims to minimize pain.

C. Administering the injection quickly might reduce discomfort but does not address the child’s emotional needs or ensure proper understanding of the procedure.

D. Explaining the procedure in simple terms helps the child understand what will happen, reducing fear and promoting cooperation. This is an important aspect of atraumatic care.

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention would the nurse include when providing atraumatic care?

Correct Answer is C

Explanation

An acute care nurse is caring for a pediatric client diagnosed with diabetes mellitus who receives insulin injections. Which of the following actions by the nurse demonstrates atraumatic care?

Correct Answer is D

Explanation

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